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Case Study Video Assignment  #3: Maggie Smith- Sore Throat

Students Names ________R________________________________________________________

 

Case Study Video Assignment  #3

Maggie Smith- Sore Throat

 

 

Students will watch the video and fill in the blanks on the documentation.

  1. Complete the SOAP Note. (We have given the history on this note).
  2. Describe 3 of the highest possible differential diagnosis. Rule-in and Rule-out each diagnosis.  Example: If a patient presents with a painful knee and your top differentials are osteoarthritis, ACL, and Fracture, you would find Evidence to prove that each of those are possible diagnosis.  For osteoarthritis: Rule in:  What signs and symptoms match what the patient has.  Give the evidence (from peer reviewed based information) to show that the symptoms match.  Then rule out: What is lacking to show this is the actual diagnosis?  You must prove your thoughts with peer reviewed information
  3. Complete the Illness script for 3 differential diagnosis.

 

 

SUBJECTIVE:

CC

 

HPI – 19-year-old established patient accompanied by her roommate for complaint of abdominal pain that is increasing in pain.

  • Onset –
  • Location-
  • Duration –
  • Character –
  • Aggravating factors –
  • Alleviating factors –
  • Timing –
  • Severity –

 

PMH – A hx of dysmenorrhea.  Treated with ortho-cyclin since age 15 years which has been effective for tx of dysmenorrhea.  Patient ran out of ortho-cyclin 2 months ago and has not follow-up for a prescription refill.

Medications – Past – Ortho-cyclen.  Occasional Tylenol for headache, fever, discomfort…

 

Mother- 45 years Hx of HTN, and hyperlipidemia. Hysterectomy at age 30 due to ovarian cancer.

Father – 45 years Hx of DM II

Sister – age 28 – healthy

Brother – age 25 – diagnosed with bipolar disease dx at age 18 years.

MGM – Deceased at age 60 – breast cancer, hx of HTN

MGF –  65 years, Alive, HTN, Hyperlipidemia

PGM – History not known

PGF – History not known

PSH-Appendectomy 1 year ago, no hospitalizations, Vaginal delivery with no complications

Social hx: Attending TTU for elementary education.  Active in her church.

G0, P0 Last menstrual cycle 1 month ago.  Is sexually active with 2 partners.  Uses a condom most of the time.  Admits to oral and vaginal intercourse.

 

ROS:

 

 

 

 

OBJECTIVE DATA

 

 

 

 

Assessment

 

 

 

 

 

Plan: What tests will you run (give rationale)

 

 

 

 

 

Illness Scrip Differentiate #1
Epidemiology  
Time Course  
Clinical Presentation  
Pathophysiology  
Lab  
Imaging  

 

 

 

 

Illness Scrip Differentiate #2
Epidemiology  
Time Course  
Clinical Presentation  
Pathophysiology  
Lab  
Imaging  

 

 

 

Illness Scrip Differentiate #3
Epidemiology  
Time Course  
Clinical Presentation  
Pathophysiology  
Lab  
Imaging  

Maggie Smith Case #2 & #3

Maggie Smith Case #2 & #3
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeSubjective

Includes Appropriate CC, History of Present Illness, Personal and Family History, medications, Allergies, and ROS. Includes VS and Exam description. Written appropriately for a SOAP Note

35.0 pts

26-35 points

Student includes all pertinent Subjective information and does not include Objective information. Terminology and writing is appropriate for SOAP note.

30.0 pts

25-30 points

A portion of the subjective information is not included or a portion of the objective information is included. Terminology and writing is lacking for SOAP note.

25.0 pts

0-25 points

A large portion of the Subjective information is missing or a large amount of Objective information is included. Terminology and writing is poor for SOAP note.

35.0 pts
This criterion is linked to a Learning OutcomeObjective information

Includes VS and Exam description. Written appropriately for a SOAP Note

35.0 pts

26-35 points

Student includes all pertinent Objective information and does not include Subjective information. Terminology and writing is appropriate for SOAP note.

30.0 pts

25-30 points

A portion of the Objective information is not included or a portion of the Subjective information is included. Terminology and writing is lacking for SOAP notes.

25.0 pts

0-25 points

A large portion of the Objective information is not included or a large amount of Subjective information is included. Terminology and writing is poor for SOAP note.

35.0 pts
This criterion is linked to a Learning OutcomeAssessment

The Assessment is written with correct terminology for this case

10.0 pts

8-10 points

The Assessment is written correctly for this case with demonstration of fair understanding of a SOAP note and with correct terminology.

7.0 pts

4-7 points

The Assessment is written correctly for this case with demonstration of good understanding of a SOAP note and with correct terminology.

3.0 pts

0-3 point

The Assessment is written correctly for this case with demonstration of poor understanding of a SOAP note and with incorrect terminology.

10.0 pts
This criterion is linked to a Learning OutcomePlan

The Plan for a comprehensive exam should include any follow-up for this patient. Include any future plans for exams, diagnostics, ect…. that might be appropriate.

10.0 pts

8-10 points

Documentation of an appropriate plan for future diagnostics and or follow-up for this patient. Demonstrates understanding of information to be documented in a plan.

7.0 pts

4-7 points

Documentation of a plan for future diagnostics and or follow-up for this patient. Demonstrates some understanding of information to be documented in a plan.

3.0 pts

0-3 point

Documentation of a poor plan for future diagnostics and or follow-up for this patient. Demonstrates poor understanding of information to be documented in a plan.

10.0 pts
This criterion is linked to a Learning OutcomeIllness Script

Complete the illness script for 3 priority differentials. Answers should be short, including only pertinent information.

5.0 pts

4-5 points

Script is completed with pertinent information for 3 differential diagnosis.

3.0 pts

2-3

Script is completed with fair information for 3 differential diagnosis

1.0 pts

0-1 points

The script is poorly written with minimal effort.

5.0 pts
This criterion is linked to a Learning OutcomeScholarly Writing

Writing is written at the graduate level with no spelling errors. Citations and the reference page are written correctly.

5.0 pts

4-5 points

The assignment demonstrates excellent understanding of graduate level work with appropriate language and terminology and no spelling errors. Citations and reference page are written correctly according to APA format.

3.0 pts

2-3 points

The assignment demonstrates fair understanding of scholarly writing with good grammar and appropriate medical terminology. Few spelling errors <3.

1.0 pts

0-1 points

The assignment demonstrates poor understanding of scholarly writing with poor grammar and inappropriate medical terminology. More than 3 spelling errors.

5.0 pts
Total Points: 100.0

 

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